mbruno at PENNSTATEHEALTH.PSU.EDU
Tue Apr 18 18:21:07 UTC 2017
Yes, and I think the most difficult part for most people is Step #2 – accepting (and understanding) the level of uncertainty that is always present.
I am quite convinced that the root cause of the problem of over-testing (including unnecessary CT scanning) that we all experience on a daily basis occurs mostly because physicians—like most people—are extremely uncomfortable with uncertainty. Some of the over-testing/over-scanning is also likely related to the practice of defensive medicine, of course, but I am convinced that most of it is done in a futile attempt to attain a higher level of certainty than is actually possible. Doctors are generally not all that facile with the tools of probability & statistics, which are essentially tools for quantifying uncertainty, but instead tend to think in either/or terms when considering diagnostic possibilities.
I’m reminded of a very funny scene from the popular TV show Cheers, which ran from 1982 –1993, in which the character Frasier Crane reads the opening words of Dickens’ A Tale of Two Cities to his friends gathered around the eponymous Boston bar. “It was the best of times, it was the worst of times,” he says. A long, uncomfortable silence follows.
Finally, one of the listeners asks, “Well, which was it?”
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Michael A. Bruno, M.S., M.D., F.A.C.R.
Professor of Radiology & Medicine
Vice Chair for Quality & Patient Safety
Chief, Division of Emergency Radiology
Penn State Milton S. Hershey Medical Center
• (717) 531-8703 | 6 (717) 531-5737
• mbruno at pennstatehealth.psu.edu<mailto:mbruno at pennstatehealth.psu.edu> |
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From: Grubenhoff, Joe [mailto:Joe.Grubenhoff at CHILDRENSCOLORADO.ORG]
Sent: Tuesday, April 18, 2017 11:51 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Intellectual humility
This intellectual humility would certainly be a good defense against sunk costs, search satisficing, confirmation bias. Is not intellectual humility another way of acknowledging uncertainty. Or perhaps acknowledging uncertainty is the next step.
Step 1: I am humble enough to know that I don’t know everything (knowledge and humility)
Step 2: Since I don’t know everything, I must acknowledge the uncertainty inherent in my conclusion (uncertainty)
Step 3: I must gather enough evidence to be reasonably certain of my conclusion (diagnosis)
Step 4: I must act based on a reasonable amount of certainty (treat)
Step 5: I must acknowledge that if my treatment does not result in the expected outcome, I must reassess my conclusion (humility, uncertainty, diagnosis, treatment and feedback = calibration).
This principle of intellectual humility allows the diagnostician to take reasonable action while allowing the diagnostician to reassess. It is equally important in promoting gathering a reasonable amount of additional information and avoiding overtesting. The strong opinion weakly held means that if my treatment of presumed septic shock doesn’t yield the expected results, I might consider something else like PE (a case at our institution).
Excellent thought exercise. Thanks!
From: Centor, Robert [mailto:rcentor at UABMC.EDU]
Sent: Tuesday, April 18, 2017 7:48 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] Intellectual humility
I just wrote a blog post based on a fascinating article about intellectual humility. In it I suggest that this trait could help us minimize some diagnostic errors. I would love the group’s comments:
A personality trait that may help us minimize diagnostic errors
Robert M Centor, MD, MACP
Chair-Emeritus, ACP Board of Regents
Professor, General Internal Medicine
1530 3rd Ave S
Birmingham, AL 35294-3407
Fax : 205-975-7797
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